DS-3024 Chest X-Ray and Classification Worksheet

OMB No. 1405-0113
EXPIRATION DATE: xx/xx/xxxx
ESTIMATED BURDEN: 10 minutes
(See Page 2 - Back of Form)

U.S. Department of State

CHEST X-RAY AND CLASSIFICATION WORKSHEET
For Use with DS-2053

Complete Sections 1 through 5, As Applicable

Name (Last, First, MI)

Age
Passport Number

Birth Date (mm-dd-yyyy)

Alien (Case) Number

1. Chest X-Ray Needed (mark all that apply)
TB signs or symptoms

History of tuberculosis (TB) disease
Contact with person with TB
(If child does not have any of the above, stop here)
2. Chest X-Ray Findings

Adult (with or without any of the other)
Date Chest X-Ray taken (mm-dd-yyyy)

Normal findings
(indicate findings and interpretation, checking all that apply, and any other in table below)

Abnormal finding

Can suggest INACTIVE TB
(Need smears if symptomatic)

Can suggest ACTIVE TB
(Need smears)

OTHER X-ray findings

Infiltrate or consolidation

Discrete fibrotic scar or linear opacity

Any cavitary lesion

Discrete nodule(s) without calcification
Discrete fibrotic scar with volume loss
or retraction
Discrete nodule(s) with volume loss or
retraction
Other (such as bronchiectasis)

Nodule with poorly defined margins
(such as tuberculoma)
Pleural effusion
Hilar/Mediastinal adenopathy

Follow-up needed
Musculoskeletal
Cardiac
Pulmonary
Other
No follow-up needed for
Pleural thickening, diaphragmatic tenting,
blunting costophrenic angle, solitary calcified
nodule or granuloma or minor
musculoskeletal or cardiac finding

Linear, interstitial markings
Other

(such as miliary findings)

Remarks

3. Sputum Smears
No, applicant has no signs or symptoms of TB and :

X-ray suggests INACTIVE TB, this is a Class B2/TB
OTHER X-ray findings suggest follow-up needed after arrival, this is B Other
OTHER X-ray findings suggest no followup needed, this is No Class
X-ray Normal, this is No Class

Yes, applicant

(mark all that apply) :

and smear results are:
Positive

Negative

Dates obtained (mm-dd-yyyy)

Signs or symptoms of TB present, See Section 1
X-ray suggests ACTIVE TB, See Section 2

Sputum smear results and X-ray findings:
At least one smear result POSITIVE and
Any chest X-ray finding, this is

Class A/TB

(Normal or Abnormal findings)

Three smear results NEGATIVE and
X-ray Normal with
Signs of symptoms resolved, this is

No Class

Signs or symptoms suggest follow-up needed after arrival, this is B Other
X-ray suggests ACTIVE or INACTIVE TB, this is Class B1/TB
OTHER X-ray findings suggest follow-up needed after arrival, this is Class B Other

4.

No Class

Class A/TB

Class B1/TB

Class B2/TB

Class B Other, follow-up needed

5. Follow-up Needed After Arrival
Remarks

DS-3024

TB condition
If Yes, for
Not TB condition
No
Yes
(If yes, specify condition below and on DS-2053; include additional tests, and therapy used with start and stop dates and any changes)

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PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
Public reporting burden for this collection of information is estimated to average 10
minutes per response, including time required for searching existing data sources,
gathering the necessary data, providing the information required, and reviewing the
final collection. Persons are not required to provide this information in the absence of a
valid OMB approval number. Send comments on the accuracy of this estimate of the
burden and recommendations for reducing it to: the U.S. Department of State

We ask for information on this form, in the case of applicants for immigrant visas, to
determine medical eligibility under INA Sections 212(a) and 221(d), and, in the case
of refugees, as required under INA Section 412(b)(4) and (5). If an immigrant visa is
issued or refugee status granted, you will convey this form to the Department of
Homeland Security (DHS) for disclosure to the Center for Disease Control and the
US Public Health Service. Failure to provide this information may delay or prevent the
processing of your case. If an immigrant visa is not issued or refugee status is not
granted, this form will be treated as confidential under INA Section 222(f).

DS-3024

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